Analysis of kidney and liver exchange transplantation in India (2000-2025): a multicentre, retrospective cohort study

In India, where deceased organ donation rates are relatively low, living donor transplantation programmes face challenges due to ABO incompatibility and sensitisation. Approximately one-third of healthy, willing living donors are incompatible with their intended recipients due to these factors. No large-scale data are currently available on kidney exchange (KE) or liver exchange (LE) transplants in low- and middle-income countries, including India.

We conducted a multicentre, retrospective cohort study including KE (2000-2024) from 65 centres and LE (2007-2025) from 7 centres across India. The living donors were near-related donors without altruistic and deceased donors. Demographic and clinical data of both donors and recipients were included in the study. The reasons for KE/LE, post-transplant outcomes with respect to patient and graft survival, rejection episodes, and donor outcomes were analysed. Kidney allocation system guidelines were: (i) Thorough pre-transplant work-up of DRP was completed before allocation to avoid chain collapse. (ii) A policy of non-anonymous allocation was practised (in contrast to anonymous allocation in high-income countries), where pairs can create a rapport during evaluation and surgery. (iii) Simple two-way exchanges, and simultaneous surgeries were considered for less experienced transplant centres in order to avoid donor renege.

A total of 1839 KE and 259 LE transplants were included in the study. The distribution of KE transplants included, 1594 (87%), 147 (8%), 44 (2%), 20 (1%), 24 (1%), and 10 (0.5%) transplants from 2-way, 3-way, 4-way, 5-way, 6-way and 10-way KE, respectively. Reasons for joining KE in transplanted pairs were ABO incompatibility 1610 (87%), compatible pairs 126 (7%), and sensitisation 103 (6%). There was notable gender imbalance, as more males were KE recipients 1504 (82%) and more females were donors 1469 (80%). The majority of LE were 2-way swaps (125 two-way vs. 3 three-way swaps), predominately involving male recipients (222 male vs. 37 females) and for ABO incompatibility.

Our largest-to-date cohort study supports that swap transplants are medically simple, but logistically complex. Access to KE or LE was unequally distributed and likely under-used. If replicated, our experience could increase access to transplants and help combat the looming threat of commercial transplants.

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